Risk factors for microalbuminuria in black americans with newly diagnosed type 2 diabetes.

We conducted a cross-sectional analysis to describe the prevalence of and risk factors for microalbuminuria among blacks with newly diagnosed type 2 diabetes. Black adults with diagnosed type 2 diabetes mellitus of 2 years' duration or less who presented for care to the Grady Diabetes Clinic (Atlanta, GA) between January 1, 1994, and December 31, 1996, were eligible (n = 1,167). Information obtained at the initial visit included age; sex; body mass index (BMI); serum total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, C-peptide, serum creatinine, and hemoglobin A1c (HbA(1c)) levels; and seated systolic and diastolic blood pressures. Outcome was urine albumin-creatinine (Alb/Cr) ratio at the initial visit. Alb/Cr ratios were categorized as normal (Alb/Cr <25 microgram/mg), microalbuminuric (Alb/Cr, 25 to 250 microgram/mg), and macroalbuminuric (Alb/Cr >250 microgram/mg). Patients with macroalbuminuria or creatinine levels of 2 mg/dL or greater were excluded. We used multiple linear regression to assess the joint association between HbA(1c) level, mean arterial pressure (MAP), and log-transformed Alb/Cr, controlling for other covariates. Of 1,044 patients studied, macroalbuminuria was present in 3.8%, and microalbuminuria, in 23.4%. Alb/Cr was independently associated with increased HbA(1c) level (P = 0.0070), MAP (P = 0.0001), BMI (P = 0.0156), log-transformed triglyceride levels (P = 0.0031), C-peptide level of 6.5 ng/mL or greater (P = 0.0007), serum creatinine level (P: = 0.0068), and male sex (P = 0.0220). The relationship between HbA(1c) level and microalbuminuria was stronger in patients with lower BMIs. Microalbuminuria prevalence was high in this population of urban blacks with newly diagnosed type 2 diabetes. Risk factors associated with increased Alb/Cr included male sex, poor glycemic control, endogenous hyperinsulinemia, high blood pressure, elevated triglyceride levels, and obesity.

Topical antimicrobials applied to the umbilical cord stump: a new intervention against neonatal tetanus.

BACKGROUND: Previous case-control studies of neonatal tetanus (NNT), a leading cause of infant mortality in developing countries, have suggested that antimicrobials applied after delivery to the umbilical cord stump may protect against this disease. However, assessment of their protective effect has been limited by the low prevalence of antimicrobial use in developing countries. METHODS: We conducted a population-based, matched, case-control study to assess the use of antimicrobials and other factors potentially related to NNT in rural parts of Bangladesh. We studied 359 cases (infants who were normal at birth but who died between the 3rd and 30th day of life after an illness characterized by signs of NNT), each matched to three living controls for gender, residence, and date of birth. RESULTS: In univariate analyses, the application of either antibiotics or disinfectants at delivery, and the continuous or any application of disinfectants were protective against NNT. The application of antibiotics at delivery (odds ratio [OR] = 0.21, P = 0.019), hand washing by the delivery attendant (OR = 0.64, P = 0.005), and prior maternal immunization with tetanus toxoid (OR = 0.50, P < 0.001) remained protective in conditional logistic-regression analyses. Application of animal dung to the umbilical stump (OR = 2.31, P = 0.047) was hazardous. CONCLUSIONS: Effective and inexpensive topical antimicrobials provide a new prevention opportunity that could be used by traditional birth attendants and mothers to provide additional benefits to NNT control programmes based on maternal immunization with tetanus toxoid. Promotion of hygienic delivery and cord-care practices and increasing tetanus toxoid coverage remain cornerstones for the prevention of NNT deaths.

PIP: Neonatal tetanus (NNT) is a leading cause of infant mortality in developing countries. Findings from previous case-control studies of NNT have suggested that antimicrobials applied following delivery to the umbilical cord stump may protect against the disease. However, assessment of their protective effect has been hampered by the low prevalence of antimicrobial use in developing countries. The authors conducted a population-based, matched, case-control study to assess the use of antimicrobials and other factors potentially related to NNT in rural parts of Bangladesh. 359 cases were studied, infants who were normal at birth but who died between the 3rd and 30th day of life after an illness characterized by signs of NNT. Each case was matched to 3 living controls for gender, residence, and date of birth. Univariate analyses found the application of either antibiotics or disinfectants at delivery, and the continuous or any application of disinfectants to protect against NNT. The application of antibiotics at delivery, hand washing by the delivery attendant, and prior maternal immunization with tetanus toxoid remained protective in conditional logistic-regression analyses. The application of animal dung to the umbilical stump was hazardous.

Genital Chlamydia infections in sexually active female adolescents: do we really need to screen everyone?

PURPOSE: To evaluate current Chlamydia trachomatis screening guidelines, which recommend that all sexually active female adolescents undergoing a pelvic examination be tested for chlamydial infection, and determine if instead providers should target particular subpopulations of these adolescents. METHODS: Data were collected from 148,650 sexually active females, ages 15-19 years, tested by direct immunofluorescent antibody in 160 family planning clinics from 1988-92. Trends in chlamydia prevalence by demographic, behavioral, and clinical risk factors were analyzed. Logistic regression modeling was used to identify selective screening criteria. Predictive models were developed for all years combined, as well as for the years when prevalence was highest and lowest. RESULTS: The prevalence of C. trachomatis in this population was 10%, with a 42% decrease (13.2-7.6%) over the 5-year period. Logistic regression identified nine demographic, behavioral, and clinical predictors (p < 0.0001) associated with chlamydial infections. Predictor models from the highest and lowest prevalence years varied little from the combined model. Individual year predictor models showed poor sensitivity and were similar for these 2 years. The screening criteria could not identify a group of adolescents with a prevalence less than 6%. CONCLUSIONS: Several individual risk factors were strongly associated with C. trachomatis, but no single risk factor or combination of risk factors used for selective screening could identify more than 42% of infections in our population. These findings support earlier national recommendations and the need for universal screening of sexually active female adolescents.

Risk factors for self-reported uterine fibroids: a case-control study.

To identify risk factors for uterine fibroids, a case-control design used to analyze data from control subjects enrolled in the Cancer and Steroid Hormone Study. Case patients were 201 women who reported a history of uterine fibroids, and control subjects were 1503 women without fibroids, individually matched by age to case patients. Reporting of fibroids was more frequent among premenopausal women, women who had frequent Papanicolaou (Pap) smears, women who used oral contraceptives and had infrequent Pap smears, and women with higher education. Reporting of fibroids was less frequent among women with a lower body mass index who were current or long-time smokers.

Neonatal tetanus in rural Bangladesh: risk factors and toxoid efficacy.

OBJECTIVES: Tetanus continues to be a leading cause of neonatal death in Bangladesh as in other developing countries, yet little is known about risk factors or the efficacy of tetanus toxoid in this setting. METHODS: In May 1990, mothers of 6148 infants born alive between March 15, 1989, and March 14, 1990, in 30 rural unions of Rajshahi Division in Bangladesh were interviewed. Three surviving controls for each neonatal tetanus death were matched for sex, residence, and date of birth. RESULTS: Of 330 neonatal deaths, 112 met the case definition for tetanus. Risk was increased with a history of neonatal tetanus in a previous child, application of coconut oil to the vagina, and use of multiple ties on the umbilical cord. Risk was reduced by the birth attendant washing hands and using a cleaned cord-cutting tool. Risk was not reduced by a maternal history of two doses of tetanus toxoid (TT2), although estimated efficacy of TT2 was 45% (95% confidence interval = 16% to 64%). Subsequent to the survey, a reference laboratory reported to potency in three consecutive lots of tetanus vaccine from the production laboratory in Bangladesh. CONCLUSIONS: These findings identify high-risk mothers, stress the importance of washing hands and cleaning the cord-cutting tool, and demand improved quality control of tetanus vaccine production.

The associations of alcohol drinking and drinking cessation to measures of the immune system in middle-aged men.

To estimate the association between the immunologic responses of the cell-mediated and humoral systems and alcohol drinking, we used data from the Vietnam Experience Study conducted by the Centers for Disease Control. That study, conducted from 1985 to 1986, was based on a random sample of 4462 male, Vietnam-era, U.S. veterans. By using linear regression, we evaluated how (1) the number of alcoholic drinks the subjects consumed per month and (2) the drinking cessation of certain subjects were associated with their relative and absolute T, B, CD4, and CD8 lymphocyte counts and immunoglobulin A (IgA), IgM, and IgG levels. We used geometric means and percentage differences in geometric means of immune status to measure the associations and adjusted these values to account for the effect of covariates. The results indicated that measures of immune status differed among the drinking categories and that, generally, the differences changed after adjustment for covariates. These differences consisted, as alcohol consumption increased, of higher IgA and IgM levels, relative T and CD4 lymphocytes, and the ratio of CD4 to CD8 cells, and of lower IgG levels, relative B and CD8 lymphocytes, absolute lymphocyte, and lymphocyte subset counts after adjusting for other covariates. Among former drinkers, we found no clear-cut pattern in measures of immunity for a few years after cessation and then found that values of former drinkers tended to return toward values of nondrinkers as they continued to abstain.

Hospitalizations involving gastroenteritis in the United States, 1985: the special burden of the disease among the elderly.

While diarrheal disease is a well-recognized problem in children, its impact in the elderly has not been adequately assessed. Among the 4.06 million hospitalizations in 1985 in the McDonnell-Douglas Health Information System database, 98,185 hospitalizations, including 1,130 deaths, had gastroenteritis recorded as a discharge diagnosis. The authors analyzed the 87,181 hospitalizations and 514 deaths for which gastroenteritis was one of the top three diagnoses. Gastroenteritis was among the top three diagnoses in 9% of all hospitalizations of children 1-4 years of age, compared with 1.5% of hospitalizations throughout adulthood (greater than or equal to 20 years). Only 0.05% of hospitalizations involving gastroenteritis were fatal for children younger than 5 years, compared with 3% in individuals 80 years or older. While children aged less than 5 years and adults aged 60 years or more each comprised one-fourth of hospitalizations involving gastroenteritis, the older group represented 85% of diarrheal deaths. Age was the most important risk factor for death subsequent to a hospitalization involving gastroenteritis (odds ratio = 52.6, 95% confidence interval 37.0-76.9 for age greater than or equal to 70 years vs. less than 5 years). Gastroenteritis is a large, underemphasized public health problem among the elderly, among whom its case-fatality ratio is higher than in children.

The associations of race, cigarette smoking, and smoking cessation to measures of the immune system in middle-aged men.

To estimate the association between the immunologic responses of the cell-mediated and humoral systems and race or tobacco smoking, we used data from the Vietnam Experience Study conducted by the Centers for Disease Control. That study, done from 1985 to 1986, was based on a random sample of 4462 male, Vietnam-era, U.S. veterans. Racial groups were white, black, Hispanic, Asian, and American Indian. We used linear regression to evaluate how (i) the race of the subjects, (ii) the number of pack-years of cigarettes the subjects smoked, and (iii) the smoking cessation of certain subjects were associated with their relative and absolute T, B, CD4, and CD8 lymphocyte counts and immunoglobulin A (IgA), IgM, and IgG levels. The results indicated that immune status was associated with race and smoking history and that, generally, the associations remained after adjustment for covariates. For example, the average IgA level and absolute CD8 lymphocyte count for blacks were, respectively, 19 and 16% higher than those for whites. On the other hand, smokers had lower immunoglobulin levels and relative CD8 cell counts and higher counts for other lymphocytes of the cell-mediated system than nonsmokers. For example, the average absolute B count of heavy smokers was 37% higher than that of nonsmokers. The pattern after cigarette smoking cessation was consistent with a reversible effect of smoking and a return toward immune levels of nonsmokers.

A reassessment of risk factors for neonatal tetanus.

A hospital-based case-control study was conducted to further examine the risk factors for neonatal tetanus (NNT) in the North-west Frontier Province of Pakistan. Three control infants were concurrently evaluated for each of 102 consecutively diagnosed NNT cases hospitalized over an 8-week period. Application of clarified butter (ghee) during the first few days of life was shown to be a significant risk factor, confirming our previously reported finding. However, the risk appeared to be limited to ghee made in the home from cow's milk. The tool used to cut the umbilical cord was again refuted to be a risk factor; application of topical antibiotics conferred significant protection. Multivariate analysis of the matched data showed that delivery by persons with academic training (physicians, nurses, and lady health visitors) was also protective. Mothers with a past history of NNT babies were shown to have a significantly increased risk, and accounted for more than one-third of all cases in the present study. The findings suggest possible ways to augment the effectiveness of NNT elimination programmes.

PIP: A hospital-based case-control study was conducted to further examine the risk factors for neonatal tetanus (NNT) in the Northwest Frontier Province of Pakistan. 3 control infants were concurrently evaluated for each of 102 consecutively diagnosed NNT cases hospitalized for over an 8-week period. Application for clarified butter (ghee) during the 1st few days of life was seen as a significant risk factor, confirming the previously reported finding of the authors. However, the risk appeared to be limited to ghee made in the home from cow's milk. The tool used to cut the umbilical cord was again refuted to be a risk factor; application of topical antibiotics conferred significant protection. Multivariate analysis of the matched data showed that delivery by persons with academic training (physicians, nurses, and lady health visitors) was also protective. Mothers who had a past history of NNT babies were shown to have a significantly increased risk and accounted for more than 1/3 of all cases in the present study. The findings suggest possible ways to augment the effectiveness of NNT elimination programs. (author's)

Identifying the malnourished within Peru: regional variation in the performance of a nutrition indicator.

Malnourished children may also have siblings at increased risk of poor health. Early identification of siblings at risk could lead to timely intervention to prevent the development of malnutrition or other potentially life-threatening events. In a nationwide survey conducted in Peru in 1984, stunting in an older sibling (defined as height/age less than or equal to 3.00 SD of the NCHS/CDC reference median) was evaluated as an indicator for stunting in a target sibling (next youngest) sibling) (n = 3284). The prevalence of stunting was much higher in target siblings who had an older sibling with stunting compared to those whose older sibling was not stunted, with prevalence ratios of 8.5 in Lima, 4.7 in urban areas, and 2.5 in rural areas. Screening indices (sensitivity, specificity, and predictive value positive) also showed marked variation across regions. The variation in this indicator's performance across regions demonstrates the importance of evaluating screening tools within the populations where they will be applied. Regional variations in the performance of malnutrition indicators should be anticipated because malnutrition is the result of a complex, multifactorial process.

Bias associated with differential hospitalization rates in incident case-control studies.

Berkson's bias reflects a statistical phenomenon in which differential hospitalization rates create an exposure distribution among hospitalized cases that differs from that among other cases. Importantly, previous work on Berkson's bias has not explicitly addressed the possibility of excluding prevalent or previously diagnosed cases--exclusions that are key features of many study designs. We indicate that the classically described bias differs from the corresponding bias in studies, such as incidence density studies, in which cases are restricted to those with recent diagnoses. We present methods that may be used to assess the magnitude of Berkson's bias in incidence-density studies. In many, though not all, situations the bias should be small and of little practical concern.

High school football injuries: identifying the risk factors.

This epidemiologic survey of the literature on the factors contributing to the high number of high school football injuries consolidates the current information on the characteristics and risk factors associated with these injuries. To reduce the incidence of knee sprains and strains, the most common injuries to this population, the following preventive recommendations are presented: 1) optimum maintenance of playing fields; 2) use of the soccer-style shoe; 3) noncontact and controlled activities in practice sessions; and 4) increased vigilance over technique during injury-prone preseason practices. The authors conclude that more research into factors such as exposure time and activity at injury will further reduce the risk to the high school football player.

High school football injuries: identifying the risk factors.

This epidemiologic survey of the literature on the factors contributing to the high number of high school football injuries consolidates the current information on the characteristics and risk factors associated with these injuries. To reduce the incidence of knee sprains and strains, the most common injuries to this population, the following preventive recommendations are presented: 1) optimum maintenance of playing fields; 2) use of the soccer-style shoe; 3) noncontact and controlled activities in practice sessions; and 4) increased vigilance over technique during injury-prone preseason practices. The authors conclude that more research into factors such as exposure time and activity at injury will further reduce the risk to the high school football player.

High school football injuries: evaluation.

An epidemiologic survey of the literature on high school football injuries revealed methodologic problems. These numerator-denominator inconsistencies and other confounding factors are discussed. The authors suggest a more reliable system of reporting these parameters to further reduce the risk of high school football injuries.

Analytic thinking: educating students for the practice of modern medicine.

The medical school curriculum is dominated by efforts to teach the mass of facts that comprise an ever-expanding pool of biomedical knowledge. As a result, little time remains for learning the scientific method, how to evaluate medical information, and how to apply analytic processes for the prevention, diagnosis, and management of disease. A new component in the medical curriculum at Emory University School of Medicine, a course titled Analytic Medicine, is proposed as a first step toward correcting these deficiencies. Analytic Medicine is intended to provide the opportunity and the necessary skills, through a problem-oriented approach, for medical students to learn to reason scientifically and to utilize analytic processes, including computers, in making clinical decisions.

Antibiotic-resistance transfer in Yersinia enterocolitica.

Most clinical isolates of Yersinia enterocolitica have been reported to be inhibited by a wide variety of antimicrobial agents. This finding indicates that Y. enterocolitica infrequently acquires resistance by gene transfer from other bacteria in nature. In the present study the authors examined whether Y. enterocolitica has the potential for acquiring antibiotic resistance from another organism in vitro. Mixed cultures of multiple-antibiotic-resistant Escherichia coli and a sensitive Y. enterocolitica yielded resistant Y. enterocolitica. Resistance to at least four drugs was transferred at a frequency of approximately 10(-7) transconjugants per donor. The newly resistant Y. enterocolitica transferred resistance to a sensitive E. coli at a slightly higher frequency. Resistance to at least one antibiotic was transferred to all five strains of Y. enterocolitica tested.